Water Safety Policy. Lead Manager. Corporate General Manager Facilities. & Infection Control Manager

Transcription

1 Water Safety Policy Lead Manager Corporate General Manager Facilities & Infection Control Manager Responsible Director Approved By Director of Facilities Board Infection Control Committee & SCART Steering Group Date Approved 28 Jan 2013 Date for Review 12 months from date of approval Page 1 of 29

2 Contents Page 1. Scope of the Policy 4 2. Introduction 4 3. Approach to the Prevention of Legionellosis Primary Objectives Roles and Responsibilities Governance Structure for Water Systems Management Management Responsibilities and Designated Staff Functions Infection Control Manager Responsible Person Water Designated Person Authorising Engineer Authorised Person Competent Person Maintenance Tradesman Tradesman Installer Contractor Contract Supervising Officer Ward and Departmental Staff Record of Appointments 8 4. Training 8 5. System Description 8 6. Planned Preventative Maintenance (PPM) 9 7. Evaluation Of Control Measures Annual Compliance Review/Audit Quarterly Compliance Review/Audit Actions in the Event of Legionella Contamination in a System Management of Contractors Safety Documentation Design and Installation of Building Services Risk Assessment High Risk Areas Cold Water Systems and Storage Tanks Hot Water Provision and Distribution Systems Water Temperatures at Outlets Scald Prevention Thermostatic Mixing Valves (TMV s) and Thermostatic 16 Mixing Taps (TMT s) 18. Intermittently Used Outlets and Showers Showerheads/hoses and Spray Outlets Buildings out of use at weekends or overnight Service Interruption (Maintenance) Policy Buffer Vessels Annual Mechanical System Check Trace Heating on Domestic Water System (if fitted) Point of Use Water Heaters Flexible Hoses Further Control Strategies Permanent Background Disinfection Point of Use Filtration Record Keeping Monitoring for Legionella (Sampling) Disinfection of Water Systems Chemical Disinfection Thermal Disinfection Cooling Towers and Evaporative Condensers Air Conditioning Systems 22 Page 2 of 29

3 Contents Page 33. Legionella Infection Potentially Acquired In Hospital Action in the event of a Nosocomially acquired case of Legionnaires 22 Disease 35. Actions in the event of an outbreak Policy Review Guidance Guidance for neonatal units (NNU s) (levels 1,2 & 3) adult and 25 paediatric intensive care units ICU s in Scotland to minimise the risk of Pseudomonas aeruginosa infection from water Appendix 1 SOP for Flushing of Taps and Showers in Clinical Areas 27 Page 3 of 29

4 1. Scope of the Policy The purpose of this policy is to detail the procedures adopted by Estates, to ensure that Hot and Cold Water, Supply, Storage and Distribution Systems in NHS GG&C are maintained and operated in accordance with the principles of SHTM and ACOP L8 and other relevant legislation and guidance. It incorporates the national Guidance for neonatal units (NNU s) (levels 1,2 & 3) adult and paediatric intensive care units ICU s in Scotland to minimise the risk of Pseudomonas aeruginosa infection from water. In particular the standards set out within this policy, when implemented, will address the first point of the six critical control points. This policy is written in support of the general statements and principles as set out in the NHS Greater Glasgow and Clyde Health and Safety Policy. 2. Introduction The aim of this policy is to ensure the provision of a safe and reliable Hot and Cold Water Supply, Storage and Distribution System which complies with NHS Greater Glasgow & Clyde s Infection Control Manual. NHS GG&C attaches the greatest importance to the health, safety and welfare of staff, patients and visitors. It is considered essential that management and staff should work together positively to achieve an environment compatible with the proper provisions of services to patients, where health hazards to staff and others are reduced to a minimum. The Health & Safety Commission s Approved Code of Practice and Guidance Legionnaires Disease The control of Legionella bacteria in water systems L8 (ACOP L8), and the Scottish Health Technical Memorandum SHTM 04-01; The control of Legionella, hygiene, safe hot water, cold water and drinking water systems, provides the necessary strategy for GG&C to achieve this relative to the hazards imposed. These are the principal guidance documents. It is accepted, that it is for management and staff to do all that is so far as is reasonably practicable to achieve compliance with the Relevant Legislation and other guidance with regard to the prevention and control of Legionella and other water borne organisms and these procedures have been laid out for this specific use within the NHS GG&C estate. Where appropriate, training and information will be provided by NHS GG&C on local actions to be taken to ensure the provision of safe water systems. It is the intention of NHS GG&C to ensure the effective implementation of this policy and to keep it under consideration in all aspects of health practice and decision making. The aim of these procedures is to prevent so far as is reasonably practicable, danger to persons at risk from Hot and Cold Water, Supply, Storage and Distribution Systems, and to those who operate, test, maintain or repair them. 3. Approach to the Prevention or Control of Legionellosis 3.1 Primary Objectives The primary objective is to maintain the management procedures, consequently ensuring that the system compliance is continuing and not notional thus providing safe systems for the benefit of the patient, staff, visitors and the environment. Ensuring the primary objectives are obtained shall be achieved as follows; Page 4 of 29

5 The appointment by the Director of Facilities, in writing, Designated Person (Legionella), Responsible Person and Deputy, for each Sector, whose duties are defined in Section 3.4 To formulate a specific Operational Procedure/Written Scheme to ensure the overall integrity of domestic water systems and equipment in compliance with ACOP L8 and SHTM To survey and carry out a risk assessment of all relevant systems and equipment to establish any items of non-compliance in accordance with the Operational Procedure/Written Scheme; To establish a programme of modification or upgrade of such systems and equipment to work toward compliance; To ensure the design of relevant building services for new, refurbished or modified systems is such that the guidance outlined in SHTM (PART A) is followed; Maintain as-fitted drawings of all existing and new, domestic water pipework systems, or where this is not possible representative schematic diagrams as a minimum Maintain operation and maintenance manuals of domestic water plant and equipment; Implement a programme of staff training to ensure that those appointed to devise strategies and carry out control measures are appropriately informed, instructed and trained and should be assessed as to competency. 3.2 Roles and Responsibilities The framework of accountability and responsibility for managers and staff on the implementation of this policy follow that laid out within the Health and Safety Policy. 3.3 Governance Structure for Water Systems Management Board Clinical Governance Forum Board Infection Control Committee Water Safety Group Responsible Person Legionella Responsible Person Pseudomonas Health and Safety Service Manager Sector Legionella Groups Page 5 of 29

6 3.4 Management Responsibilities and Designated Staff Functions. Management is defined as the owner, occupier, employer, general manager, chief executive or other person who is ultimately accountable, and on whom the duty falls, for the safe operation of healthcare premises. A person intending to fulfil any of the staff functions specified below should be able to prove that they are competent by possessing qualification, sufficient skills, knowledge and experience to be able to perform safely the designated tasks. The Key Personnel who have specific responsibilities within SHTM are: Infection control Manager The Infection Control Manager, the Infection Prevention and Control Doctor (also known as the Infection Control Doctor) and the Consultant Microbiologist are nominated by management to advise on infection control policy and to have responsibility for the provision of advice on the maintenance of water quality Responsible Person (Water) A Responsible Person, possessing adequate professional knowledge and with appropriate training, should be appointed in writing by management to devise and manage the necessary procedures to ensure that the quality of water in healthcare premises is maintained. The Responsible Person should be a Manager or Director or have similar status or sufficient authority to ensure that all operational procedures are carried out in an effective and timely manner. The Responsible Person will be required to liaise closely with other professionals in various disciplines. In addition, the Responsible Person should possess a thorough knowledge of the safe management of hot and cold water systems and would ideally be a chartered engineer, microbiologist or other similar professionally qualified person. This role, in association with the nominated sector infection control doctor and maintenance staff, involves: Advising on the potential areas of risk and identifying where systems do not adhere to this guidance; Liaising with the water authority and environmental health departments and advising on the continuing procedures necessary to ensure acceptable water quality; Monitoring the implementation and efficacy of those procedures; Approving and identifying any changes to those procedures; Ensuring equipment that is to be permanently connected to the water supply is properly installed; Ensuring adequate operating and maintenance instructions exist and adequate records are kept. Implementation of an effective maintenance policy must incorporate the preparation of fully detailed operating and maintenance documentation and the introduction of a logbook system. The Responsible Person shall appoint a deputy in writing to whom delegated responsibilities may be given. The deputy should act for the Responsible Person on all occasions when the Responsible Person is unavailable. The Responsible Person should be fully conversant with the design principles and requirements of water systems and should be fully briefed in respect of the cause and effect of water-borne organisms, for example Legionella pneumophila. The appointment of an engineer is appropriate in that the role can extend to the operation and maintenance of associated plant. Page 6 of 29

7 It is recognised that the Responsible Person cannot be an expert on all matters and must be supported by specialists in specific subjects such as water treatment and microbiology, but he/she must undertake responsibility for calling upon and coordinating the activities of such specialists. The Responsible Person should be aware that manufacturers, importers, suppliers, installers and service providers have specific responsibilities that are set out in the Health and Safety Commission s Approved Code of Practice L Designated Person The Designated Person provides the essential senior management link between the organisation and its professional support, which also provides independence of the audit-reporting process. The Designated Person will also provide an informed position at Board level Authorising Engineer An Authorising Engineer acts as an independent professional advisor to the healthcare organisation, appointed by the organisation with a brief to provide services in accordance with Scottish Health Technical Memorandum (SHTM) guidance. The Authorising Engineer acts as an assessor, making recommendations for the appointment of Authorised Persons, monitoring the performance of the service and providing an annual audit to the organisation s Designated Person Authorised Person The Authorised Person has the key operational responsibility for the service, qualified and sufficiently experienced and skilled for the purpose. He/she will be nominated by the Authorising Engineer and be able to demonstrate His/her application through familiarization with the system and attendance at an appropriate professional course; A level of experience; Evidence of knowledge and skills. An important element of the Authorised Person s role is the maintenance of records, quality of service and maintenance of system safety (integrity). The Authorised Person will also be responsible for establishing and maintaining the roles and validation of Competent Person who may be employees of the organisation or appointed contractors. Larger sites may require more than one Authorised Person for a particular service Competent Person The Competent Person provides skilled installation and/or maintenance of the specialist service. He/she will be appointed, or authorised to work (if a contractor) by the Authorised Person. He/she will demonstrate a sound trade background and specific skill in the specialist service, working under the direction of the Authorised Person in accordance with operating procedures, policies and standards of the service Maintenance Tradesman A Maintenance Tradesman is someone who has sufficient technical knowledge and the experience necessary to carry out maintenance and routine testing of the water, storage and distribution system. Page 7 of 29

8 3.4.8 Tradesperson A Tradesperson is someone who is appointed in writing by the Responsible Person to carry out, under the control of the Maintenance Tradesman, work on the water, storage and distribution system Installer An Installer is the person or organisation responsible for the provision of the water, storage and distribution system Contractor A Contractor is the person or organisation designated by management to be responsible for the supply, installation, validation and verification of hot and cold water services, and for the conduct of the installation checks and tests. In relation to the control of Legionella, it is essential to ensure that potential contractors have suitable qualifications (for example companies/individuals who are members of the Legionella Control Association) Contract Supervising Officer The Contract Supervising Officer is the person nominated by the management to witness tests and checks under the terms of contract. He/she should have specialist knowledge, training and experience of hot and cold water supply, storage and mains services Ward and Department Staff Will be aware of the hot and cold water risk assessments within Estates and any implications for them as individuals. Will know that they have a responsibility to self-report any suspected adverse health effects to the Estates Department or Responsible Person. Will know that they can obtain advice and support from Health and Safety as required. Full cognisance must be duly taken of the Health and Safety Control Book, which incorporates relevant operational procedures, method statements and risk assessments. 3.5 Record of Appointments The Director of Facilities will keep a record, in writing of appointments of Designated Persons. The Designated Person will hold and maintain a file recording the appointment of the Responsible Person(s) within the Board. The Responsible Person for each sector will hold and maintain a file recording all other appointments as required by ACOP L8 and SHTM The Responsible Person will maintain a file and record of all other appointments as required by ACOP L8 and SHTM Training All training received by Personnel with responsibilities within this policy will be recorded in the individual s personal training file. The requirements for training will be the successful completion of approved courses, run by an approved training organisation and/or the manufacturers of the equipment. Routinely the Responsible Person or his/her Deputy should carryout system training and familiarisation, in accordance with ACOP L8/SHTM Page 8 of 29

9 5. System Description NHS Greater Glasgow and Clyde has over 120 premises which range from acute hospitals to small health centres/ clinics. Each System is described in the Site Operational Maintenance Plan. This general Operational Procedure/Written Scheme will apply to all buildings. However, each building will have a system/building specific legionella risk assessment which should be consulted in order to create the planned preventative maintenance programme required for the individual property. 6. Planned Preventative Maintenance (PPM) Planned Preventative Maintenance (PPM) is carried out through a combination of direct labour and specialist contractors. The PPM is based on periodic inspections recommended in Suppliers Operating and Maintenance Manuals, ACOP L8 & SHTM and on the findings of the Legionella Risk Assessments. The Responsible Person will ensure that a list and description of the main plant and equipment is available and that instructions to start, operate, control and shut down the systems are all known and fully understood by the Technician(s) and Trade Person(s)/Contractor(s). A planned preventative maintenance database/planner is used to record and forecast planned maintenance activities for all hot and cold water systems and their associated equipment. PPM Tasks Required for L8/SHTM Compliance Frequency Flushing of all outlets in unoccupied areas and little-used outlets Cold outlets should be flushed until the water temperature drops and stabilises at Twice Weekly <20 C and then for a further 3 minutes. Hot outlets until temperature stabilises at >50 C and then for further 3 minutes 1 Flushing of deadlegs/blind ends where these cannot be removed, cold deadlegs should be flushed until the water temperature drops and stabilises at Twice Weekly <20 C and then for a further 3 minutes. Hot deadlegs should be flushed until temperature stabilises at >50 C and then for further 3 minutes. (Or until removal is carried out) 1 Alternation of booster pumps Weekly (ensuring every pump runs at least sequentially weekly) Alternation of hot water secondary circulation pumps Weekly (ensuring every pump runs at least weekly) Test to confirm booster, recirculation and de-stratification pumps operating correctly Weekly Calorifier storage temperatures checks at top (flow), return and base Monthly Flow temperature Min 60 C, Base/return temperature min 50 C Temperature checks on point of use/multi point water heaters Monthly Flow temperature Min 55 C. *Also note potential scald risks Temperature checks on hot outlets at sentinel, little-used & selected outlets. >50 C within 1 minute. 2 Monthly (ensuring every outlet is tested at least once per annum) *Also note potential scald risks Temperature checks on cold outlets at sentinel, little-used & selected outlets. <20 C within 2 minutes. Monthly (ensuring every outlet is tested at least once per annum) Descaling, cleaning and disinfection of showerheads & hoses & spray outlets Quarterly Flushing of calorifier bases (until water runs clear) Quarterly 1 Ensure aerosol creation is kept to a minimum when flushing low use outlets and deadlegs 2 Hot supply temperatures in Healthcare Premises may vary (e.g. 55 C at sentinel outlets, mixer valves, pantries, kitchens, laundries etc.) Please refer to SHTM 04/01 for further details. Page 9 of 29

10 Inspection and descaling of taps/outlets if required (frequency may alter dependent on inspection results and hardness of water on site) Quarterly Review of Legionella Policy, Operation Procedures/Written Scheme and Planned Preventative Maintenance Programme and remedial work progress/action Plan (e.g. Quarterly/Annual Legionella Group Meeting) CWST condition inspection noting appearance of water, stagnation, odour, rust, scale, sediment, debris, paint/liner condition and bio film accumulation and tank lid Six Monthly fitting ok and insulation condition as well as exterior and tank room condition. CWST temperature checks on tank supply and stored water at opposite side from tank inlet if possible (inlet and stored water should be <20 C, with stored water no Six Monthly more than 2 C warmer than make-up water.) Servicing TMV s or mixer valves, including fail safe tests and cleaning/disinfection of Six Monthly strainers. (More frequently if manufacturer recommends) Check to ensure entire body of calorifier (Top, Middle, Base) reaches 60 C for a period of 1 hour each day (generally at a time of low use e.g. early morning/late Six Monthly evening). Removal and inspection of system strainers, with cleaning and disinfection carried Six Monthly out as required (more frequently if recommended by manufacturer) Flush buffer and pressurisation vessel quarterly. cont... N.B. Filters fitted to domestic water system should be changed/cleaned in accordance with manufacturer s instructions and site PPMs. PPM Tasks Required for L8/SHTM Compliance (cont...) Frequency Turnover test on cold water storage system. Checks should be carried out to ensure that volume of water stored is no more than would generally be used in a normal 24 hour period Internal inspection and cleaning/descaling of the calorifier/water heater with disinfection/ pasteurisation upon completion Inspection of vibration couplings on pumps/plant, replacing as necessary (or as per manufacturers recommendations) Inspection & cleaning of buffer vessels and accumulators (more frequently if recommended by manufacturer) Inspection of plant and pipework insulation, repairing as and when necessary. Test to ensure that plant temperature & pressure gauges and thermostats are accurate. Arrange for microbiological samples to be taken from cold water tanks, remote from float valve, sentinel and little used outlets, calorifier base and any other areas of concern based on information in risk assessment and L8 monitoring records. All sampling should be carried out in accordance with BS 7592:2008 and all analysis by a UKAS accredited laboratory. 3 Cleaning and disinfection of water services in accordance with BS6700 as and when required (dependant on inspection/sample results). Treatment of surface corrosion and other remedial works to be carried out as necessary where highlighted Annually Annually Annually Annually Annually Annually Six Monthly or as required. As Required Pasteurisation of calorifier/water heaters carried out as and when required As Required dependent on temperature monitoring and sample results Identify, Label and log all plant, valves and services As Required Identify, label and log sentinel outlets on hot and cold water services As Required 1 Sampling regime should be formulated by the Responsible Person (in conjunction with Infection Control Team) and based on the known history of the water systems and the details included within the risk assessment and L8 monitoring records, with assistance of specialist legionella consultant if necessary. although L8/SHTM does not specifically request legionella sampling. In cases where there are incorrect distribution or supply temperatures, water quality issues or other factors which may increase the likelihood of legionella proliferation and dissemination sampling should be carried out. 7. Evaluation of Control Measures Page 10 of 29

11 Review Procedures are required to ensure the correct implementation of this Policy and the Operational Procedures/Written Scheme for the NHS GG&C properties are being managed effectively. 7.1 Annual Compliance Review/Audit The Responsible Person will be responsible for the formal review of the implementation of the Operational Procedure/Written Scheme within the sites under their remit, the purpose being to determine the correct operation of the control measures in place and their efficacy. An annual review meeting should be held at which all members of the Legionella Control Team, Responsible Persons (and Deputies) and any other relevant parties will attend. The recommendations arising out of the review will be recorded and implemented at the soonest available opportunity. A review of the most recent Legionella Risk Assessment will be a standing item on the meeting agenda including an assessment of progress on the implementation of the Action Plan arising from the risk assessment. The Annual review will include a review of the NHS GG&C Policy and Operational Procedures/Written Scheme. 7.2 Quarterly Compliance Review/Audit The Responsible Person will on a quarterly basis, through a designated deputy(s), make inspections and checks to establish that the necessary preventative planned maintenance measures (control measures) are in place and effective. Records of inspections and checks will be held and signed off by the Responsible Person. Inspections and Checks will include: Progress assessment of Action Plans Confirmation and evidence that all testing regimes are in place and functioning Confirmation and evidence that all planned and corrective maintenance actions are being completed Assessment of incomplete Incident Reports (i.e. those where remedial actions identified have not been fully auctioned) Should a breakdown of the control measure occur, a DATIX report will be completed by the Responsible Person (or designated deputy), detailing the nature of the breakdown. The Responsible Person, in conjunction with other relevant parties, will investigate the causes of the breakdown and identify and prioritise the remedial action(s) required through a Critical Incident Review including all members of the Legionella Control Team within the investigation. This will be documented by the Responsible Person and held on file for record purposes, monitoring of the necessary corrective action(s) being formally documented through the quarterly review process. 8. Actions in the Event of Legionella Contamination in a System Where Legionella bacteria is detected within any plant and/or system within properties under the remit of NHS GG&C the Responsible Person will, in conjunction with other appropriate personnel/contactors and ICD investigate accordingly in order to determine the cause of the contamination and identify and prioritise any remedial actions required. The event will be recorded within DATIX (raised by the Responsible Person or other authorised person) which will be processed as per the normal reporting procedures and actioned appropriately. The Responsible Person will retain a file of all such incident reports (within Legionella Logbook) along with records of all remedial actions taken and any/all subsequent legionella sample results. Electronic copies of documentation will be added to the DATIX report. Page 11 of 29

12 9. Management of Contractors All contractors will comply with the Management of Contractors Policy. They will report to the Estates Department upon arrival at the relevant location, where they will report to the Responsible Person (or designated contact) to receive any necessary briefing or instructions in relation to the work to be carried out. The contractor will log in. Any necessary permits and identification will be issued. Signatures will be taken to record access and reference to the relevant Asbestos Register has been made. On completion of the work, or prior to the Contractor leaving the site for the day, he/she will contact the Estates Department. 10. Safety Documentation When carrying out work on Pressure Systems or in Confined Spaces a permit to work will be issued. No work will be done on any water systems, other than that which has been authorised by the Responsible Person or his Deputy or other authorised person. Work will only be carried out by authorised or competent person(s) or contractor(s). The suitability of all third party contractor staff will require to be assessed by the Responsible Person or his Deputy or other authorised person person(s), before they are permitted to carryout work on Pressure Systems or in Confined Spaces. All work will be conducted in accordance with the instructions contained in one or more of the following documents:- Permit to Work Method Statement Prior to raising any of these documents a Risk Assessment of the process to be undertaken shall be conducted. This shall be attached to the Method Statement, which will fully address the risk identified, so as to minimise these. The Method Statement once issued must be strictly adhered to. In the event of any hot and/or cold water services requiring to be taken out of use, full discussions with the Estates Department will take place prior to the work commencing. 11. Design and Installation of Building Services All new installations shall be designed so as to comply with the content and spirit of this policy, or any other relevant documents. Certain fittings and materials used in water systems may support bacterial or fungal growth. Examples include leather, some rubbers, jointing compounds and mastics, wooden packing and certain plastics. The "Water Fittings and Materials Directory" published on line by the Water Regulations Advisory Scheme (WRAS) lists fittings and materials which are approved for use. New installations and alterations to existing installations for NHS GG&C shall incorporate only those fittings and materials published as approved in the latest edition of the Directory available at Risk Assessment A suitable and sufficient Legionella Risk Assessment shall be carried out to identify and assess the risk exposure to legionella bacteria from NHS GGC work activities. When: There is reason to suspect that the risk assessment is no longer valid; Page 12 of 29

13 There has been a significant change in the work to which the risk assessment relates; or The results of any monitoring carried out in accordance with regulation 10 (COSHH) show it to be necessary, and where, as a result of the review, changes to the risk assessment are required, those changes shall be made. If there has been a change in legislation or new information comes to light regarding the organism. The risk assessment will be carried out by persons deemed competent to carry out the works. This will require proof of training and of competency, i.e. suitable experience and training to carry out the assessment effectively. Specimen assessments of previous works should be obtained for examination and approval as well as 3 rd party references of the suitability of the contractor or consultant undertaking the works. All risk assessments should be carried out according to BS 8580:2010 Water quality Risk assessments for Legionella control Code of practice as well as with due consideration to ACOP L8 and SHTM The following systems and equipment types have been identified as those which may pose a threat from Legionella and will therefore require to be addressed as such by the operation system at each location; It is not an exhaustive list. Domestic Hot Water Systems Domestic Cold Water Systems Cooling Towers Evaporative Condensers Wet Components in Ventilation (Air Conditioning) Systems Cassette Air Conditioning Units Portable Air Conditioning Units/Humidifiers (These should not be used in Hospitals) Hydrotherapy Pools Water Features Medical Gases Systems Respiratory nebulisers Ice Making Machines Vending & Chilled Water (Drinking) Non potable water storage such as fire systems. Wet fire systems Deluge/Emergency Showers Lawn sprinklers/garden hoses Vehicle wash equipment Trolley Wash/pressure washers Ornamental fountains Sanitary assemblies Flowers/plant water and compost Any other system and/or equipment which is prone to water stagnation or other forms of microbiological contamination Many of these systems have been implicated in Legionella cases or outbreaks, some of these are effectively banned from hospital sites and there is specific guidance in the SHTM04-01 and L8 as well as other guidance notes on the control of these specific systems which should be consulted and incorporated into the specific written scheme for each building. 13. High Risk Areas In addition to the assessment of the water systems and associated equipment, Clinical Staff input should also be sought to determine the locations of High Risk areas within the NHS GG&C premises, that is, those areas occupied by patients who are particularly susceptible to infection. Where Legionella bacteria are detected in high risk areas, the risk assessment carried out shall take account of this and will call for more stringent remedial action than for all other areas. A list of high risk areas will be contained within the Operational Procedure/Written Scheme. Healthcare areas should be classified as follows: High Risk - Patients with AIDS, Haematological malignancy and end stage renal disease, or other severe immune deficiency likely to be present. Page 13 of 29

14 Medium Risk - Patients with diabetes, chronic lung disease and non haemotogical malignancy likely to be present. Low Risk - All other clinical and non-clinical areas. In specialty departments where patients are particularly susceptible (such as renal wards, transplant units, cancer care areas), it may be preferable to provide separate small-scale domestic water systems. Such systems should have independent supply and local heating sources. The use of point of use, hands free water heaters mounted over sinks should be considered. Additionally, local water treatment may be considered necessary. It is also vital that cold water should be maintained below 20 C. 14. Cold Water Systems & Storage Tanks Ideally cold water should be stored and distributed at temperatures below 20 C. However, the Supply Regulations allow the water companies to supply cold water at up to 25 C and this storage condition may therefore not always be met. Where water is supplied at a temperature above 20 C further measures such as background dosing, increased flushing/turnover or legionella and other microbial testing may be required. The cold water in storage and at outlets should be not more than 2 C above the supply water temperature. Where water storage tanks are in use to supply cold water services the storage tanks shall be suitable for wholesome water, easily cleaned, equipped with a close fitting cover and adequate drain valve, suitably insulated to minimise heat gains, and having overflow/warning pipes properly screened. Tanks should ideally have take-off and entry points at opposite ends to ensure a flow through the tank. Total water storage shall be such that under normal use complete turnover takes less than 12 hours. Where possible the layout of cold services and tanks should ensure that water in the system does not gain heat. Tanks and pipe work should not be positioned close to heat sources or where they could be affected by solar gain, unless they are effectively insulated. Where multiple storage tanks are fitted pipework design should be such that all storage tanks draw off equally so as to prevent stagnation. If stagnation or low use is suspected the required volume of water and design of the services should be assessed in order that required remedial actions can be undertaken. Any services taken out of use should not contribute to deadleg formation. In summary they should conform and be fitted in accordance with the Water Regulations Guide 1999 including the Water Byelaws 2004 (Scotland) guidance, ISBN and the most recent applicable SHTM Hot Water Provision & Distribution Systems Calorifiers should be capable of heating water stored within them to the required temperatures of 60 C throughout, this should be confirmed monthly and should be able to be opened for inspection and cleaning. It should be possible to isolate them, and they should incorporate drain connections at the lowest points which are large enough to permit the removal of sludge and quick drainage of the vessel. Calorifiers should be purged of sediment, until the water runs clear on a quarterly basis. Instances of cold water running from the drain may suggest poor circulation in the calorifier and the operation of the destratification pump, heating element or calorifier design should be reviewed if stratification is occurring as a temperature zone conducive to Legionella growth will occur. Where warming of the cold feed supply pipework to the calorifier occurs then suitable engineering measures/remedial actions may be required but in only in accordance with the relevant guidelines, manufacturer s instructions and SHTM and the Water Regulations Guide/Water Byelaws (Scotland). Page 14 of 29

15 Pipe work runs should be as short and direct as practicable. On new systems or on refurbishment or alteration, spurs from circulation loops shall not exceed 3 metres in length. Ideally hot water circulation pumps shall be of adequate performance to maintain a minimum return temperature of 50 C. Far sentinel points on the hot water distribution system should ideally reach 55 C. Return temperatures less than this or slow to rise hot water outlet temperatures can also be symptomatic of incorrectly functioning flow and return circuits and should be investigated to ensure the flow and return system is operating correctly otherwise large stagnant sections of water services, with temperatures in the legionella growth range, may be present leading to microbial and biofilm proliferation and subsequent contamination of the system. Where the site has in place a building energy management system (BEMS) then this should be utilised to monitor flow and return temperatures. Hot water circulation systems should not be shut down unless in an emergency. Calorifiers which are taken out of use should be isolated and drained with the drain valve left open until the unit is returned to use. If the unit is only out of use for a few days or less then it shall be refilled, drained refilled again and the contents heated throughout to 60 C for a minimum of 1 hour prior to return to service. The calorifier should be isolated during this process. Calorifiers out of use for longer periods should be disinfected either by chemical means or via pasteurisation for an hour prior to reinstatement; again the unit should be isolated during the process. Hot water systems shall not be used for space heating and shall not feed towel rails, radiators etc. 16. Water Temperatures at Outlets The flow temperature from hot water calorifiers or other bulk water heaters should not be less than 60 C. The minimum temperature anywhere in the circulation pipe work should not be less than 50 C and preferably be maintained above 55 C with checks made at the nearest and farthest sentinel points. Water temperatures at calorifiers and sentinel hot and cold outlets shall be measured and recorded monthly. Results should be recorded on a log sheet. According to the SHTM 04-01, a further number of outlets shall be tested every year to ensure as a minimum 20% of all outlets are tested so that over 5 years 100% are tested. ACOP L8 requires this to be carried out annually Please note that outlets in high risk areas should also be considered as sentinel outlets and ACOP L8 advises all outlets are tested annually. Therefore, the SHTM should be taken as a minimum standard, though where practicable the L8 standard should apply with all outlets tested annually. Cold water outlet temperatures shall be measured after allowing the water to run at full flow for 2 minutes. The temperature should be less than 20 C, or if 20 C or above should be less than 2 C above the incoming supply from the water supply company. Further preventative actions will be required under these circumstances. Hot water outlet temperatures shall be measured after allowing the water to run at full flow for up to 1 minute. The temperature should be at least 50 C and preferably 55 C at farthest sentinel points. However, where mixing or blending devices are used which prevent the hot outlet reaching this temperature, the pipe surfaces immediately before the device should reach 50 C for the hot supply within 1 minute and less than 20 C within 2 minutes for the cold supply. Some manufacturers recommendations are that the hot inlet temperature to their TMV s should be 55 C to ensure safe operating conditions. Page 15 of 29

16 Any large deviations/peaks/troughs of temperature on hot or cold should be reported and investigated even if the final hot and cold temperatures are satisfactory after the allotted times as this may imply wider system problems which can lead to microbiological proliferation and biofilm formation especially where the outlets are little used. 17. Scald Prevention Thermostatic Mixing Valves (TMVs) & Themostatic Mixing Taps (TMT s) Where people at risk of scalding (as determined by appropriate risk assessment/infection Control) are served by the hot water system, "fail-safe" TMV-3 (tested and accepted by the BuildCert TMV scheme) thermostatically controlled mixing valves and thermostatically controlled mixing taps, may be used (i.e. valves or taps which are unaffected by changes in water pressure and automatically close the hot water supply if the cold water fails). Those people at risk of scalding include young children, the very old, and those with sensory loss. The TMV-3 should be positioned as close as possible to the hot water outlets and should not exceed 2 metres and where possible with one TMV feeding a single outlet, or installed in such a way that that there is no detrimental impact on performance on the system and the total downstream blended water pipework remains less than 2 metres in length. The total hot pipework length from the hot circulation pipework to the outlet (via TMV) should remain within the 3 metre distance as referred to previously. The TMT-3 is part of the tap so is immediately at the outlet. Central blending of hot water should not be used. The TMV s/ TMT s fitted and their location should be such that it allows for easy access for servicing and maintenance of the unit, for instance with easily removable filters and have an appropriate method of identification such as a bar code or id number. TMV s should be serviced regularly to ensure safe operation but also to ensure the valve does not allow bypassing to occur or to allow debris to build up in the strainers. Ideally they should be services and tested on a minimum 6 monthly basis as per Health Technical Specification D08/Manufacturers instructions. They should be designed to reduce the hot water temperature at the outlet to between C dependant on application (see SHTM and the Thermostatic Mixing Valve Manufacturers Association guideline for Recommended Code of Practice for Safe Water Temperatures for further guidance). Limits for hot and cold supply temperatures to the TMV are the same as for hot and cold water outlets using a surface probe to check. Advice on safe water temperatures should be sought at the design stage of all new projects. TMV s / TMT s at the near and far points on the system, and considered sentinel outlets, should have the surface temperatures monitored and they should comply with the same temperature limits as sentinel hot and cold water outlets. 18. Intermittently Used Outlets and Showers The need for intermittently or infrequently used taps and appliances (particularly showers) shall be reviewed quarterly, with a formal review on a annual basis, or more often where possible, by the Responsible Person in consultation with other relevant parties. Records of these reviews will be held within the system logbooks. If such taps and appliances are not necessary, wherever possible the supplies shall be cut and piped through. Where this is not possible then pipework shall be cut back as close to the main/recirculating line as practical to ensure that any deadleg formed is minimised. Nursing and other staff must be made aware of the issues surrounding legionella contamination and the link to low and underused services and their assistance in formally identifying these possible outlets sought. A policy for the implementation of the twice weekly minimum flushing of the water services will be formulated with relevant parties. Page 16 of 29

17 During temporary closure of wards/areas or buildings a procedure for flushing the hot and cold water services shall be implemented and recorded by the Estates Department. This will include opening all taps for a period of 3 minutes after the outlet temperature has stabilised and flushing all WC cisterns on a minimum twice weekly cycle. Some outlets may require further flushing depending on the flow rate and distance from the main circulation system. Alternatively isolation and draining of the system should be considered with a disinfection being carried out prior to the system being reinstated. 19. Showerheads/hoses and Spray Outlets. On a quarterly basis, shower heads and hoses, spray tap nozzles (where they can be removed), kitchen rinsers and any other aerosol generating equipment will be dismantled, wherever possible, cleaned and descaled/disinfected and the work logged on the shower maintenance log sheet. Completed log sheets will be held by Estates Department. Where possible all aerosol generators will be removed, or consideration of a lower spray outlet being fitted investigated. 20. Buildings out of use at weekends or overnight. The hot water services are to remain live, i.e. the calorifier and automatic systems such as auto flush WC s remain switched on as otherwise pasteurisation would be required on start up with the all the logistic issues that would entail. 21. Service Interruption (Maintenance) Policy The Estates Department will formulate a policy and emergency measures in case of interruption of supply and the possible effect this may have on the water services due to issues such as CWST drain down, airlocking in the system, mains interruption and scrubbing of supply pipework debris into the system as possible examples. 22. Buffer Vessels Buffer vessels are typically vertical in orientation and normally have a diaphragm to separate the water from the gas space above. They introduce a potential problem of colonisation by Legionella, as the plantroom space temperature will exceed that of the incoming water. Where possible they should not be installed as part of any new design, however if there is no other alternative, then they should preferably be of a design such that water flows through the vessel, entering at low level, and discharging at a higher level below the water line. Interconnecting pipework should be kept to a minimum, and the vessel should be insulated to minimise heat gain. All materials in contact with water should be WRAS-approved. 23. Annual Mechanical System Check The condition of backflow prevention valves, strainers, isolating valves, pipework and all other plant items and equipment should be checked for condition, correct operation and serviced is required. 24. Trace Heating on Domestic Water Systems (if fitted) Check routinely (monthly that the system water is above 50 C and there are no cold spots. 25. Point of Use Water Heaters (POU) Where hot water supply is proving problematic or in high risk areas consider the use of small volume, high turnover POU water heaters delivering at above 55 C and conforming to BS6700:1997. Page 17 of 29

18 26. Flexible Hoses Flexible hoses (also known as tails ) have become a convenient method of connecting between hard pipework and sanitary fittings or equipment. They typically comprise a steel braided outer sheath with a synthetic rubber inner lining. Reports have been received intimating that high levels of pseudomonas and Legionella bacteria have been found in water samples taken from outlets fed by flexible hoses lined with ethylene propylene diene monomer (EPDM) due to colonisation of the lining, although it is possible that other lining materials and washers within couplings could be similarly affected. New lining materials are now available such as polyethylene (PE), cross-linked polyethylene (PEX), linear low-density polyethylene (LLDPE) and post chlorinated PVC (PVC-C). In view of this, it is recommended that the use of flexible hoses in potable water supplies should be identified and risk assessed, taking account of areas of highest risk involving persons vulnerable to infection. An action plan should be developed for existing premises to address replacing flexible hoses by fixed piping where they had been installed solely for speed or convenience. In new build projects flexible hoses should not be specified in such situations. Where flexible hoses must be used for the likes of essential equipment subject to vibration or articulation, such as hi-low baths, consideration would be given to using the above listed alternative lining materials. Care would be required to avoid kinking or distortion during installation. Reference should be made to SHTM regarding disinfecting of hoses connected between shower mixing valves and related shower heads. Such hoses are not presently covered by the content of this Clause. Risk assessments should be reviewed regularly and whenever changes take place to the patient user group or to the potable water system. All flexible hoses must be WRAS approved. 27. Further Control Strategies 27.1 Permanent Background Disinfection Temperature control is considered to be the main method for minimising the multiplication of the legionella and other organisms in hospital water systems. However due to the complexity and age of many health care premises it is often difficult to achieve the stated control temperatures and it is therefore suitable to look at background dosing systems such as Chlorine Dioxide dosing or Copper/Silver ionisation systems to provide supplementary control of the water system. Where this may be considered an option, prior to progressing to planning installation approval must be sought from the Water Safety Group. Both ClO 2 and AG/Cu ion systems are well documented as being effective against biofilms and Legionella Please note however continual dosing of drinking water with silver ions is unacceptable. Hydrogen peroxide with stabilised silver solution is not advised for continuous background dosing but can be considered for emergency or routine disinfection. Continuous chlorine dosing is not advised due to the poor effectiveness of chlorine against biofilms at the permitted levels for potable water. Ultraviolet and ozonation systems are suitable mainly for POU applications only and are not suitable for bulk treatment of the water system. Page 18 of 29

19 Whatever system is chosen either ClO 2 or AG/Cu ion a full system survey and risk assessment should be undertaken to ensure the suitability of the treatment, its application, installation, monitoring and proving the effectiveness of the system. Purging and flushing through to low use and out of use areas will be required on a weekly basis as a minimum also if the treatment is to be effective. As these systems can potentially impact on renal/dialysis systems, laboratories and other systems a full impact assessment should be undertaken. Qualified advice should be sought on these systems prior to installation and the proposed systems assessed by the Responsible Person and the Legionella Control Group prior to approval and installation. Further information on these systems and control parameters is available in SHTM Point of Use Filtration Filtration to 0.2 micron absolute can prevent the transmission of the Legionella organism at the outlet and various types of filter for various outlets are available for both emergency control and ongoing prevention. These filters however must be replaced as per manufacturer s instruction, typically at least once a month or as required dependent on local water conditions. When changing filters, it is recommended that sampling of water quality takes place at outlets identified as sentinel points, before refitting a replacement filter. Where point of use filters and no longer required, the outlet and associated pipework must be disinfected to remove any accumulated biofilm before the system is returned to service. It must be noted however that bacteria can colonise these filters as they block the flow of the bacteria and these can then grow through the filter leading to contamination even if backwashed. The use of permanent background dosing systems or filters should not negate or impact on measures to control the water system through temperature, operation and design. 28. Record Keeping A Legionella Logbook will be held for each site and will be held by the Responsible Person. This will contain records of the Legionella Risk Assessment, all checks, tests and test results, and also a record of all storage tanks, distribution pipework calorifiers and fittings and remedial actions carried out. Relevant Schematic Drawings will also be held and will show the key components of each system and the locations of those components in the building. All records should be held for a minimum period of 5 years. 29. Monitoring for Legionella (Sampling) It is recommended that this should be carried out: when storage and distribution temperatures do not achieve those recommended under the temperature control regime and systems are treated with a biocide regime, a monthly frequency of testing for Legionella is recommended. This may be reduced as confidence in the efficacy of the treatment regime is established; In systems where the control regimes are not consistently achieved, for example temperature or biocide levels (weekly checks are recommended until the system is brought under control); When an outbreak or incident is suspected or has been identified On hospital wards with at risk patients-for example those who are immune compromise. Page 19 of 29

20 As a minimum samples should be taken as follows: Cold water system, from the cold water storage tank and the furthest outlet from the tank. Samples may also be required from other areas of particular concern, e.g. in hospitals wards with at risk patients. Hot water systems, from the calorifier outlet or the nearest tap to the calorifier outlet plus the return supply to the calorifier or the nearest tap to that return supply. Samples should also be taken from the base of the calorifier where a drain valve has been fitted and from the furthest outlet from the calorifier. Samples may also be required from areas of particular concern, e.g. in hospital wards with at risk patients. Showers and other aerosol generators should all be considered for sampling. Sampling should also be carried out in areas with known microbial or other control issues from both hot and cold services, especially in wards with high risk patients, including re-sampling of areas to prove efficacy or otherwise of remedial actions and control measures. The complexity of the system should be to taken into account in determining the number of samples taken. For example, if there is more than one ring main or multiple wings and floors in the building taps from each ring/floor/wing will need to be sampled in order for the sampling to be representative of the building water condition. There should be samples taken from the bulk water system on the hot and cold services i.e. from unblended services such as a DSR to give a separate condition for the hot and cold services as well as from blended water services such as TMV controlled taps where no unblended services are available for testing. The risk assessment and monitoring/system condition results should also be taken into consideration when formulating a sampling regime. Sampling should be in accordance with paragraph 10.4 page 60 of the SHTM The table below from SHTM details the action required following legionella sampling in hot and cold water systems. Table 4 is included below. Legionella bacteria (cfu/litre) More than 100 but less than 1000 More than 1000 Action required Either: A) If only one or two samples are positive, system should be re-sampled. If a similar count is found again, a review of the control measures and risk assessment should be carried out to identify any remedial action. B) If the majority of the samples are positive, the system may be colonized, albeit at a low level, with legionella. Disinfection of the system should be considered but an immediate review of control measures and risk assessment should be carried out to identify any other remedial action required. The system should be re-sampled and an immediate review of the control measures and risk assessment carried out to identify any remedial actions, including possible disinfection of the system. Retesting should take place a few days after disinfection and at frequent intervals thereafter until a satisfactory level of control has been achieved. Page 20 of 29

21 30. Disinfection of Water Systems According to the Approved Code of Practice L8 and SHTM water services only require to be cleaned and disinfected if: Routine inspection shows it to be necessary, or if the system or any part of it has been substantially altered or entered for maintenance purposes in a manner which may lead to contamination, or Where routine inspection of a water system shows it to be necessary, or if a system, or part of a system, has been altered or entered for maintenance purposes in a manner which may lead to contamination, then that system shall be disinfected. during or following an outbreak of legionellosis Note: Unless otherwise directed by the Responsible Person, this policy does NOT cover the cleaning and disinfection of water storage tanks, which do NOT supply domestic cold water or domestic hot water systems. In particular heating system feed and expansion tanks are outside the scope of this policy, as also are storage tanks where the water does not come into contact with patients, staff or visitors. Disinfection can be carried out in two ways: by the use of suitable chemical disinfectants, choice of chemical is dependant on the particular system, when it is necessary to disinfect the whole system including storage tanks. Note: the system will require to be neutralised following chemical disinfection. By thermal disinfection, i.e. by raising water temperature to a level at which legionella will not survive Chemical Disinfection Prior to chemical disinfection it is essential to ensure that the system is clean, and it is important to ensure that all parts of the system are disinfected, not just those that are readily accessible. Chemical disinfection is usually carried out by chlorinating the water in the cold water storage tank to mg/litre free residual chlorine for a pre determined length of time. It is then allowed to flow to all parts of the system by successively opening the outlets in the system such as taps and showers until suitable level of free residual chlorine is detected then closing them and leaving it to stand for an appropriate period. This depends on the chlorine concentration. The required concentration should be maintained in the cold water storage tank throughout the chlorination procedure and chlorine concentration needs to be monitored throughout disinfection to ensure there is a sufficient residual chlorine level. The system should be thoroughly flushed following chlorination. This treatment should not be carried out by untrained personnel and should be closely supervised. Building occupants should be warned that the water is heavily chlorinated. If tanks and calorifiers are heavily contaminated by organic materials, the system should be chlorinated before cleaning to reduce risks to cleaning staff. For both traditional chlorination and the use of other disinfectants being used they must be approved and thoroughly risk assessed and the implications of using the disinfectant understood e.g. where there is the potential treated water to come into contact with the patient(s) blood stream e.g. dialysis systems. For instance Hydrogen Peroxide with stabilised silver suspension is one possible alternative allowing systems to remain on line when dosing at appropriate permitted levels. Page 21 of 29

22 30.2 Thermal Disinfection If thermal disinfection is considered necessary the risk of scalding should be carefully considered prior to work commencing. Thermal disinfection can be carried out by raising the temperature of the whole contents of the calorifier then circulating this water throughout the system for at least an hour. To be effective, the temperature at the calorifier should be high enough to ensure the temperature at the outlets does not fall below 60 C. Each tap and appliance should be run sequentially for at least five minutes at the full temperature and this should be measured. The risk of scalding should be considered and particular care taken to ensure that water services are not used, other than by authorised personnel, until water temperatures have dropped to their normal levels. 31. Cooling Towers & Evaporative Condensers There are no cooling towers or Evaporative Condersers within NHS GG&C, none are to be installed without thoroughly investigating non wet cooling options first and the approval of the responsible person(s), infection control officer and legionella control group 32. Air Conditioning Systems Ventilation and air conditioning systems (including Split Systems for comfort cooling), shall be designed so that water, whether from the supply or from other sources such as condensation, cannot accumulate in condensate trays, ductwork or plant which is subject to an air stream. All condensate drains shall incorporate an air break as near to the ventilation or air conditioning system as possible, to prevent potentially contaminated water from being drawn back into the system. No domestic type air humidifiers, or any similar equipment which may compromise air quality, shall be put into use on GG&C premises. 33. Legionella Infection Potentially Acquired in Hospital Hospital patients, particularly those who are immune suppressed, are particularly susceptible to Legionnaires disease and the hospital environment provides many of the factors necessary for the transmission of Legionella. Consequently, hospitals have a special responsibility for the prevention of Legionnaires disease. The following classifications of nosocomial Legionnaires disease are used for surveillance purposes: Definite Nosocomial Legionnaires disease in a person who was in hospital for all ten days before the onset of symptoms Probable Nosocomial Legionnaires disease in a person who was in hospital for between one and nine of the ten days before the onset of symptoms and either became ill in a hospital associated with one more previous cases of Legionnaires disease, or yielded an isolate that was indistinguishable from isolates obtained from the hospital water system at about the same time. Possible Nosocomial Legionnaires disease in a person who was in hospital for between one and nine of the ten days before the onset of symptoms in a hospital not previously known to be associated with any cases of Legionnaires disease and where no microbiological link has been established between the infection and the hospital. Page 22 of 29

23 34. Action in the Event of a Nosocomially acquired Case of Legionnaires Disease In the event of a single case of legionellosis, possibly or definitely, acquired in premises of GG&C then an emergency meeting of the responsible person(s), Lead infection control officer, Doctor, ICM and legionella control group will be called and the Legionella policy referred to for actions. The emergency group will undertake a review of the known information regarding the case or cases and take appropriate action to minimise any further risks to staff and patients which may include elements laid out below. The group shall meet as necessary, with others as appropriate, to co-ordinate investigation of the problem, and progress any necessary action. Minutes are to be kept and a log of actions taken, and results of tests and inspections are to be recorded by the Responsible Person and the Estates Department. A photographic record should be kept where appropriate. 1. In the first instance the risk assessment, water hygiene monitoring and microbial sampling records for the areas in question and other possible areas at risk should be reviewed to ascertain if any out of specification, or points of concern, have been raised and actioned or are still outstanding. 2. A definition should be agreed and the outbreak control plan instituted. 3. Any actions raised but not implemented should be reviewed in light of the situation highlighted with priority and timescales reconsidered. Other actions which should be considered may include (in consultation with nursing and clinical staff as appropriate) 4. Stopping admissions to the ward/department/site 5. Consideration of early discharge/transfer of patients 6. Sampling water from taps, showers and other potential sources of legionella in ward/department/concerned prior to any disinfection or pasteurisation. 7. Examination of ductwork of ventilation plant to ward/department concerned, and sampling of condensate drain water from cooling coil(s) 8. Sampling of water from DHW and CWS serving ward/department prior to any disinfection or remedial works 9. Testing hot and cold water temperatures at all outlets in ward/department and checking flow and return operation 10. Elevation of DHW temperatures to C or greater if possible at outlets, and placing of warning notices of raised temperatures 11. Isolation of any showers and other spray outlets. 12. Inspection of maintenance records for legionellosis preventive work 13. Disinfection of water services in accordance with BS6700/BS EN Resampling of water systems to prove efficacy or otherwise or remedial actions. 15. Carry out remedial works as required on the system to minimise potential contamination. Page 23 of 29

24 Legionnaires disease is not notifiable under public health legislation in England and Wales but, in Scotland, legionellosis (ie all diseases caused by legionella) is notifiable under the Public Health (Notification of Infectious Disease) (Scotland) Regulations The Health and Safety Executive may be involved in the investigation of outbreaks under the Health and Safety at Work Act Actions in the event of an outbreak In addition to the Action in the Event of a Nosocomial Case of Legionnaires Disease the following steps should also be taken in the event of two or more confirmed, linked cases of Legionnaires Disease. 1. An outbreak is defined by the Public Health Laboratory Service (PHLS) as two or more confirmed cases of legionellosis occurring in the same locality within a six-month period. Location is defined in terms of the geographical proximity of the cases and requires a degree of judgement. It is the responsibility of the Proper Officer for the declaration of an outbreak. The Proper Officer is the Consultant in Public Health Medicine (CPHM) employed by the Health Board and acting as Designated Medical Officer for the local authority. 2. Local authorities will have established incident plans to investigate major outbreaks of infectious disease including legionellosis. These are activated by the Proper Officer who invokes an Outbreak Committee, whose primary purpose is to protect public health and prevent further infection. This will normally be set up to manage the incident and will involve representatives of all the agencies involved. HSE or the local authority EHO may be involved in the investigation of outbreaks, their aim being to pursue compliance with health and safety legislation. 3. The local authority, CCDC or EHO acting on their behalf (often with the relevant officer from the enforcing authorities - either HSE or the local authority) may make a site visit. 4. As part of the outbreak investigation and control, the following requests and recommendations may be made by the enforcing authority. (a) To shut down any processes which are capable of generating and disseminating airborne water droplets and keep them shut down until sampling procedures and any remedial cleaning or other work has been done. Final clearance to restart the system may be required. (b) To take water samples (see paragraphs , Part 2) from the system before any emergency disinfection being undertaken. This will help the investigation of the cause of the illness. The investigating officers from the local authority/ies may take samples or require them to be taken. (c) To provide staff health records to discern whether there are any further undiagnosed cases of illness, and to help prepare case histories of the people affected. (d) To co-operate fully in an investigation of any plant that may be suspected of being involved in the cause of the outbreak. This may involve, for example: (i) (ii) (iii) (iv) tracing of all pipework runs; detailed scrutiny of all operational records; statements from plant operatives and managers; statements from water treatment contractors or consultants. 5. Any infringements of relevant legislation, may be subject to a formal investigation by the appropriate enforcing authority. Page 24 of 29

25 36. Policy Review This policy will be reviewed after 12 months from the date of ratification, or as new knowledge on the subject evolves and subsequent guidance is issued. No changes to this policy or the associated procedures shall be made without the agreement of the Designated Person, Responsible Person, Water Safety Control Group and Infection Control Manager. 37. Guidance 37.1 Guidance for neonatal units (NNU s) (levels 1,2 & 3) adult and paediatric intensive care units ICU s in Scotland to minimise the risk of Pseudomonas aeruginosa infection from water. The following references form a compendium of literature available at the present time to which reference should be made Health & Safety at Work, etc. Act 1974 The Management of Health and Safety at Work Regulations 1999 & (Amendment) Regulations 2006 The Control of Substances Hazardous to Health Regulations (COSHH) (Amendment) Regulations 2004 Approved Code of Practice & Guidance, Legionnaires disease: The control of Legionella bacteria in water systems, L8 Public Health (Infectious Diseases) Regulations 1988 NHS Estates - Scottish Health Technical Memorandum (SHTM 04-01) The Chartered Institute of Building Services Engineers (CIBSE) - Technical Memorandum (TM13), Minimising the Risk of Legionnaires Disease Water Regulations Advisory Scheme - Water Supply (Water Fittings) Regulations 1999 Water Regulations Advisory Scheme - Water Fittings and Materials Directory The Water Byelaws 2004 (Scotland). Water Supply (Water Quality) (Scotland) Regulations 2001 Food Safety Act 1990 BS 8580:2010 Water quality. Risk assessments for Legionella control. Code of practice BS 6700; 2006, Design, Installation, Testing & Maintenance of services supplying water for domestic use within buildings & their cartilages - Specification, BS EN 806; (2010) Specification for installations inside buildings conveying water for human consumption. BS 1710; 1984 Specification for Identification of Pipelines and Services Thermostatic Mixing Valve Manufacturers Association - Recommended Code of Practice for Safe Water Temperatures Page 25 of 29

26 This policy is not intended to replace or usurp the above documents, which should be consulted for more comprehensive information and guidance. Additional information relating to the operation and control of hot and cold water systems and the control of legionella may be issued from any of the above organisation, equipment manufacturers or other competent persons and should be logged, assessed and filed with appropriate action taken as necessary. Page 26 of 29

27 Appendix 1 NHS GREATER GLASGOW & CLYDE PREVENTION AND CONTROL OF INFECTION SERVICE OR WATER SYSTEMS GROUP STANDARD OPERATING PROCEDURE FOR FLUSHING OF TAPS AND SHOWERS IN CLINICAL AREAS OF NHS GGC Page 1 of 3 Effective From Review Date Version Draft 3 1. Responsibilities HCWs must: Follow this SOP. Inform a member of the local Estates team if this SOP cannot be followed. Managers must: Support Healthcare Workers (HCWs) in following this SOP Water Systems Group must: Keep this SOP up-to-date. Audit compliance with this SOP (Weekly Assurance checklist / SPE audit) Provide guidance via the Water Systems Policy 2. Water Group Flushing Regime Flushing of sinks is necessary to control the build up of biofilm in water systems to reduce the risk of transmission of pathogens via the environment and equipment to patients. There are two main requirements under current or draft guidance: flush outlets twice per week for 3 minutes to reduce legionella risk; flush all taps in high risk environments (adult, paediatric and neonatal ICUs and associated HDU s), daily for 1 minute It is possible to combine these two criteria when considering a flushing regime. It is also useful to include the flushing carried out by domestic services staff during cleaning of the sink and tap unit. Page 27 of 29

28 NHS GREATER GLASGOW & CLYDE PREVENTION AND CONTROL OF INFECTION SERVICE OR WATER SYSTEMS GROUP STANDARD OPERATING PROCEDURE FOR FLUSHING OF TAPS AND SHOWERS IN CLINICAL AREAS OF NHS GGC Page 2 of 3 Effective From Review Date Version Draft 3 High Risk areas All sinks in high risk clinical areas including Adult, Paediatric and Neonatal ICU s and their associated HDU s must be flushed for one minute daily at the maximum flow rate. This is the responsibility of the SCN in the area. If the tap is used daily and cleaned by Domestic Services staff, it is not necessary to flush this outlet. If the ward is closed or is a little used outlet, i.e. less than 3-4 times per week, then each outlet should be flushed twice weekly for 3 minutes and recorded on a sheet. See Appendix 1. If the outlet is rarely used or not at all, then contact Estates to remove the outlet completely. Reporting SCN will be responsible for reporting to Estates on a quarterly basis using an electronic spreadsheet. This will be tabled by the Sector Estates Manager at the Sector / Local Water Safety Group and any issues of concern escalated to the Board Water Systems Group. Page 28 of 29

29 NHS GREATER GLASGOW & CLYDE PREVENTION AND CONTROL OF INFECTION SERVICE OR WATER SYSTEMS GROUP STANDARD OPERATING PROCEDURE FOR FLUSHING OF TAPS AND SHOWERS IN CLINICAL AREAS OF NHS GGC Page 3 of 3 Effective From Review Date Version Draft 3 (Example of flushing record) RECORD OF RUNNING TAPS TWICE WEEKLY ROOM NUMBER DATE SIGNATURE Page 29 of 29